Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wayne County Nursing Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was transferred using an extra-large mechanical lift sling that did not fit their body size, without a proper assessment by a nurse or therapist after hospital readmission. The care plan lacked documentation of sling size or type, and staff used the only available sling without verifying its appropriateness, resulting in the resident falling and sustaining serious injuries. Staff interviews revealed inconsistent practices and inadequate training regarding sling selection and transfer assessments.
A resident was transferred using an extra-large mechanical lift sling that did not fit their body size, without a documented assessment by a nurse or therapist to determine the appropriate transfer method after hospital readmission. The care plan lacked details on mechanical lift use and sling size, and staff inconsistently determined transfer status and equipment needs. The resident fell from the sling, sustaining serious injuries, and an audit revealed multiple slings in use without proper size labeling.
A LTC facility failed to maintain an effective infection control program, as evidenced by staff not using required PPE for residents on Enhanced Barrier Precautions, improper hand hygiene during wound care, and failure to clean shared equipment between residents. These actions were contrary to the facility's policies, leading to potential risks of infection transmission.
The facility failed to assess residents for safe self-administration of medications, resulting in unsupervised medications left at bedsides. A resident with Alzheimer's was found with multiple pills unattended, another with Parkinson's had pills left at their bedside, and a third with heart failure had a nasal spray unsupervised. None had orders or assessments for self-administration, contrary to facility policy.
A resident with severe cognitive impairment fell during a transfer using a mechanical lift, but the facility failed to investigate the incident as required by policy. Despite staff presence, no documentation or investigation was conducted to rule out abuse, neglect, or mistreatment.
Failure to Assess and Document Proper Sling Use Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents, resulting in actual harm. A resident with vascular dementia, dysphagia, chronic kidney disease, and severely impaired cognition was readmitted to the facility after hospitalization for acute respiratory failure. Upon readmission, there was no documented assessment by a registered nurse or therapist to determine the resident's transfer status or the appropriate sling size for mechanical lift use, despite the resident's unsteady gait and poor balance. The care plan and care card did not include instructions for mechanical lift use, sling size, sling type, or loop configuration. On the day of the incident, two certified nursing assistants attempted to transfer the resident using a mechanical lift after determining the resident was too weak for a walker transfer as indicated on the care card. They selected an extra-large full-body sling, which did not fit the resident's body size, and used it because it was the only available sling on the unit. The staff did not verify the resident's weight or ensure the sling was appropriate for the resident's size. During the transfer, the resident slipped through the sling, fell, and sustained a subdural hematoma and orbital fracture. The investigation revealed that several slings in the facility lacked visible size labels, and there were non-manufacturer slings in circulation. Interviews with staff indicated inconsistent practices regarding who determines transfer status and sling selection, with some staff believing certified nursing assistants could make these decisions independently. Training on sling selection and mechanical lift use was found to be inadequate, with at least one certified nursing assistant reporting incomplete hands-on training. Documentation of sling size and type in care plans was lacking, and there was confusion among staff about proper procedures for assessing residents and updating care plans after admission or readmission.
Removal Plan
- Revise the facility policy on resident admissions and readmissions to include a registered nurse assessment which addresses a resident's height, weight, shoulder circumference, and chest circumference.
- Retrain all certified nursing assistants and licensed nursing staff on the admissions and lift/transfer policies and attest that all remaining nursing staff will complete mandatory training prior to their next scheduled shift.
- Reassess all residents identified as needing a full mechanical lift for transfers and assign an appropriate lift sling.
Failure to Assess and Document Proper Sling Use Results in Resident Injury
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable well-being of each resident, as evidenced by the improper use of a mechanical lift sling during a resident transfer. After a resident was readmitted following hospitalization for acute respiratory failure, there was no documented assessment by a registered nurse or therapist to determine the appropriate mode of transfer, including the correct sling size. The resident's care plan and care card did not include information about mechanical lift use, sling size, sling type, or instructions on loop configuration. On the day of the incident, two certified nursing assistants attempted to transfer the resident using a mechanical lift and selected an extra-large sling without verifying its appropriateness for the resident's body size. The sling was applied incorrectly, and the resident slipped through, resulting in a fall that caused a subdural hematoma and an orbital fracture. The facility's investigation revealed that several slings in circulation lacked visible size labels, which are required for proper identification and safe use. An audit conducted after the incident led to the removal of nine slings without size labels from use. The investigation did not confirm whether the sling used was a Medline sling, as recommended by the lift manufacturer, nor did it address the need for reassessment of the resident's transfer status by a registered nurse or therapist following the change in condition at readmission. Observations of the facility's sling inventory showed that many slings lacked size and weight guidelines, and non-Medline slings were present in the inventory. Interviews with staff indicated inconsistencies in determining transfer status and equipment needs. The nurse educator stated that both registered and licensed practical nurses, as well as certified nursing assistants, could make decisions regarding the use of mechanical lifts and sling selection, but the sling size should be documented in the care plan. The certified nursing assistant involved in the incident reported not verifying the sling size and not knowing where to find other slings. The DON confirmed that the resident's transfer status was not assessed upon readmission and that certified nursing assistants could select the type and size of sling based on the resident's height and weight.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Resident #36, who was on Enhanced Barrier Precautions due to an indwelling urinary catheter, was not provided with the required personal protective equipment by staff during care. Certified Nursing Assistants failed to wear gowns while transferring the resident and handling the urinary drainage bag, which was also placed on the floor without a barrier. This was contrary to the facility's policy, which mandates the use of gowns and gloves for residents on Enhanced Barrier Precautions and requires urinary drainage bags to be kept off the floor. Resident #37, who had diabetic foot ulcers, received wound care from a Licensed Practical Nurse who did not adhere to proper infection control practices. The nurse failed to change gloves or perform hand hygiene between handling soiled and clean dressings and between different wound sites. This oversight was acknowledged by the nurse during the survey, indicating a lapse in following the facility's wound care policy, which requires hand hygiene and glove changes to prevent cross-contamination. Additionally, Resident #91 was transferred using a mechanical lift that had not been cleaned after use on another resident who was on Enhanced Barrier Precautions. This breach in protocol was admitted by the Certified Nursing Assistant involved, who did not recall cleaning the equipment between uses. Furthermore, Resident #94's urinary drainage bag was observed lying directly on the floor without a barrier, contrary to the facility's policy. Interviews with staff, including the Infection Preventionist, revealed confusion and inconsistency in the application of Enhanced Barrier Precautions and personal protective equipment usage, contributing to these deficiencies.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medications or have medications left at their bedside unsupervised. Three residents were involved in this deficiency. Resident #130, diagnosed with Alzheimer's disease, dementia, and anxiety, was observed with a medicine cup containing multiple pills at the dining room table without any nursing staff present. The resident's care plan did not include documentation for self-administration of medication, and there were no active medical orders for such. Resident #89, who was cognitively intact and diagnosed with Parkinson's disease, chronic pain, and depression, reported that nursing staff frequently left pills at their bedside, although they were not supposed to. The resident was not familiar with all their medications and had no care plan documentation for self-administration. Resident #119, with diagnoses including congestive heart failure, anxiety, and depression, and documented as having moderately impaired cognition, was found with a nasal spray left unsupervised at their bedside. The resident's care plan did not include self-administration of medication, and there were no active medical orders for it. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the facility's policy required a thorough assessment and a physician's order before residents could self-administer medications. However, these procedures were not followed, leading to the deficiency.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to initiate an investigation following a witnessed fall involving a resident with severe cognitive impairment and multiple diagnoses, including seizure disorder and brain tumor. The resident, who was dependent on staff for transfers, experienced a fall while being transferred from bed to wheelchair using a mechanical lift. Despite the presence of a nurse and two CNAs during the incident, the facility did not provide evidence of a thorough investigation to rule out abuse, neglect, or mistreatment, as required by their policy. The facility's policy mandates that incidents be documented immediately and investigated to determine if abuse, neglect, or mistreatment occurred. However, the facility was unable to produce an incident and accident report, witness statements, or a summary of the investigation for the fall. Interviews with staff, including the Compliance Officer, confirmed that no investigation was conducted, and no documentation was available to assess the root cause, equipment use, or need for staff re-education or care plan revision.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Lyons
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Newark Manor Nursing Home Inc | 3.5 mi | ★★★★★ | 0 | 0 |
| Wayne Health Care | 4.2 mi | ★★★★★ | 0 | 0 |
| Clifton Springs Hospital And Clinic Extended Care | 9.2 mi | ★★★★★ | 0 | 0 |
| Sodus Rehabilitation & Nursing Center | 12.8 mi | ★★★★★ | 0 | 0 |
| Finger Lakes Health | 13.1 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.